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Tintinalli's Emergency Medicine Manual, 8e

Chapter 163: Neck Injuries

Steven Go

INTRODUCTION
Neck trauma causes a diverse combination of injuries because of the high concentration of critical structures in the neck. Presenting signs of neck
injury may be obvious, subtle, or obscured by trauma to other body regions. Missed injuries and delays in diagnosis lead to increased patient
morbidity and mortality.

CLINICAL FEATURES
Historical and physical examination findings of vascular, laryngotracheal, or pharynoesophageal injury of the neck are characterized as hard or soft
signs (Table 163-1), with 90% of patients with hard signs having an injury requiring emergent repair.

Table 163-1

Signs and Symptoms of Neck Injury

Hard Soft

Vascular injury

Shock unresponsive to initial fluid therapy Hypotension in field

Active arterial bleeding History of arterial bleeding

Pulse deficit Nonpulsatile or nonexpanding hematoma

Pulsatile or expanding hematoma Proximity wounds

Thrill or bruit

Laryngotracheal injury

Stridor Hoarseness

Hemoptysis Neck tenderness

Dysphonia Subcutaneous emphysema

Air or bubbling in wound Cervical ecchymosis or hematoma

Airway obstruction Tracheal deviation or cartilaginous step-off

Laryngeal edema or hematoma

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Pharyngoesophageal injury
Odynophagia
Historical and physical examination findings of vascular, laryngotracheal, or pharynoesophageal injury of the neck are characterized as hard or soft
signs (Table 163-1), with 90% of patients with hard signs having an injury requiring emergent repair. Campbell University
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Table 163-1

Signs and Symptoms of Neck Injury

Hard Soft

Vascular injury

Shock unresponsive to initial fluid therapy Hypotension in field

Active arterial bleeding History of arterial bleeding

Pulse deficit Nonpulsatile or nonexpanding hematoma

Pulsatile or expanding hematoma Proximity wounds

Thrill or bruit

Laryngotracheal injury

Stridor Hoarseness

Hemoptysis Neck tenderness

Dysphonia Subcutaneous emphysema

Air or bubbling in wound Cervical ecchymosis or hematoma

Airway obstruction Tracheal deviation or cartilaginous step-off

Laryngeal edema or hematoma

Restricted vocal cord mobility

Pharyngoesophageal injury
Odynophagia

Subcutaneous emphysema

Dysphagia

Hematemesis

Blood in the mouth

Saliva draining from wound

Severe neck tenderness

Prevertebral air

Transmidline trajectory

Vascular injuries are the most common cervical injury and cause of death from penetrating neck trauma. Symptoms include frank exsanguination and
expanding hematomas, which may cause airway obstruction. Cervical artery injury can also cause various vascular and neurological signs and
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symptoms (Table 163-2).
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Table 163-2

Compiled Screening Criteria for Blunt Cerebral Vascular Injury

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Transmidline trajectory
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Vascular injuries are the most common cervical injury and cause of death from penetrating neck trauma. Symptoms include frank exsanguination and
expanding hematomas, which may cause airway obstruction. Cervical artery injury can also cause various vascular and neurological signs and
symptoms (Table 163-2).

Table 163-2

Compiled Screening Criteria for Blunt Cerebral Vascular Injury

Signs and symptoms

Arterial hemorrhage from nose, neck, or mouth
Cervical bruit in patients <50 years old
Expanding cervical hematoma
Focal neurologic deficit: transient ischemic attack, hemiparesis, vertebrobasilar symptoms, Horner’s syndrome
Stroke on secondary CT
Neurologic deficit unexplained by head CT
Risk factors for blunt cerebral vascular injury
High-energy transfer mechanism and one of the following:
Facial fractures: Le Fort II or III fracture, mandible fracture, frontal skull fracture, orbital fracture
Cervical spine fracture patterns: subluxation, fractures extending into the transverse foramen, fractures of C1–C3
Any basilar skull fracture or occipital condyle fracture
Petrous bone fracture
Diffuse axonal injury with Glasgow Coma Scale score ≤8
Concurrent traumatic brain and thoracic injuries
Neck hanging with anoxic brain injury
Clothesline type injury with significant swelling, pain, or altered mental status

Laryngotracheal injuries can present with immediate signs of impending airway obstruction (Table 163-3) or have an insidious onset of airway
compromise after a quiescent phase.

Table 163-3

Clinical Factors Indicating Need for Aggressive Airway Management

Stridor
Acute respiratory distress
Airway obstruction from blood or secretions
Expanding neck hematoma
Profound shock
Extensive subcutaneous emphysema
Alteration in mental status
Tracheal shift

Pharyngeal and esophageal injuries have no hard signs of injury and may initially present with few symptoms.

Neurologic injuries can result from injury to the cervical spine, spinal cord, lower cranial nerves, or brachial plexus. Symptoms can range from sensory
complaints to quadriplegia.

Strangulation is a type of blunt neck injury whose presentation largely depends on the duration and degree of vascular compression rather than on
airway obstruction. Cerebral anoxia, laryngotracheal fractures, cervical spine fractures, pharyngeal lacerations, and carotid artery injuries are
possible. The most common symptoms are neck pain, voice changes, trouble swallowing, and difficulty breathing, while common signs are petechiae
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and neck contusions. However, 50% of patients have no signs of trauma and 67% are asymptomatic. Some patients with ultimately life-threatening
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injuries are asymptomatic at presentation.
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DIAGNOSIS AND DIFFERENTIAL

Neurologic injuries can result from injury to the cervical spine, spinal cord, lower cranial nerves, or brachial plexus. Symptoms can range from sensory
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complaints to quadriplegia.
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Strangulation is a type of blunt neck injury whose presentation largely depends on the duration and degree of vascular compression rather than on
airway obstruction. Cerebral anoxia, laryngotracheal fractures, cervical spine fractures, pharyngeal lacerations, and carotid artery injuries are
possible. The most common symptoms are neck pain, voice changes, trouble swallowing, and difficulty breathing, while common signs are petechiae
and neck contusions. However, 50% of patients have no signs of trauma and 67% are asymptomatic. Some patients with ultimately life-threatening
injuries are asymptomatic at presentation.

DIAGNOSIS AND DIFFERENTIAL

The zone classification summarizes structures placed at risk for injury in penetrating neck trauma (Fig. 163-1). Zone I structures include the lung
apices, thoracic vessels, distal trachea, esophagus, cervical spine, and vertebral and carotid arteries. Zone II structures include the mid-carotid and
vertebral arteries, jugular veins, esophagus, cervical spine, larynx, and trachea. Zone III structures include the proximal carotid and vertebral arteries,
oropharynx, and cervical spine.

Figure 163-1

Zones of the neck.

In penetrating neck trauma, a careful, structured physical exam is >95% sensitive for clinically significant vascular and aerodigestive injuries. Particular
attention should be paid to whether the platysma has been violated. If violation has occurred, the presence of deep structure injury is assumed until
proven otherwise. The combination of physical examination with multidetector CT angiography (MDCTA) (100% sensitive and 97.5% specific for
significant vascular or aerodigestive injury) has been recommended over mandatory operative exploration and selective management strategies for
diagnosis in stable patients. Additional studies may be required if MDCTA detects a penetrating injury, but these are typically ordered in conjunction
with the specialist who will be repairing the suspected injury. An algorithm for the diagnosis and management of penetrating neck injuries is shown in
Fig. 163-2.

Figure 163-2

Penetrating neck trauma protocol.

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Fig. 163-2.
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Figure 163-2
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Penetrating neck trauma protocol.

Safely managing blunt neck trauma victims requires a heightened level of suspicion and an aggressive approach to diagnosis because catastrophic
injuries can present subtly. Therefore, MDCTA should be used liberally. If the MDCTA is negative, but significant suspicion of vascular injury remains,
formal cerebral angiography may be required. Likewise, if a strong suspicion of blunt laryngotracheal or esophageal injury remains after a negative
MDCTA, laryngobronchoscopy, endoscopy, or swallowing studies may be necessary.

EMERGENCY DEPARTMENT CARE AND DISPOSITION

1. Initiate standard ATLS protocol for the stabilization of trauma patients. Establish IV access, administer oxygen, and begin cardiac and respiratory
monitoring.

2. Emergent airway control is indicated for patients with the clinical factors listed in Table 163-3. Have adjunct airway devices at hand and use
paralytics with extreme caution, as these airways can be extremely difficult to secure. If oral intubation is not possible or is
contraindicated, a surgical airway is indicated.

3. Penetrating neck trauma is associated with pneumothorax and hemothorax 20% of the time. Diagnose tension pneumothorax clinically and
perform immediate needle thoracostomy. Otherwise, pneumothorax and hemothorax may be detected by bedside ultrasound or chest radiograph,
and tube thoracostomy is indicated.

4. Apply direct pressure with hemostatic dressings to control active hemorrhage without occluding carotid arteries or the airway. Blind clamping of
blood vessels is contraindicated due to a risk of subsequent neurovascular injury. Topical hemostatic agents may be used along with
direct pressure. If direct pressure fails, inflating a Foley catheter in the wound tract may help control hemorrhage. Administration of tranexamic
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acid 1 g intravenously over 10 minutes then 1 g intravenously over 8 hours should be considered in exsanguinating patients with wounds less than
Chapter 163: Neck Injuries, Steven Go Page 5 / 6
3 hours old. Uncontrolled hemorrhage despite these measures requires emergent surgery.
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5. Immobilize the cervical spine in patients with altered level of consciousness, blunt trauma, or penetrating trauma with neurologic deficits after
careful examination for penetrating injury, bleeding, hematoma, or bruits/thrills. Cervical collars should not be placed at the expense of
 perform immediate needle thoracostomy. Otherwise, pneumothorax and hemothorax may be detected by bedside ultrasound or chest radiograph,
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and tube thoracostomy is indicated.
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4. Apply direct pressure with hemostatic dressings to control active hemorrhage without occluding carotid arteries or the airway. Blind clamping of
blood vessels is contraindicated due to a risk of subsequent neurovascular injury. Topical hemostatic agents may be used along with
direct pressure. If direct pressure fails, inflating a Foley catheter in the wound tract may help control hemorrhage. Administration of tranexamic
acid 1 g intravenously over 10 minutes then 1 g intravenously over 8 hours should be considered in exsanguinating patients with wounds less than
3 hours old. Uncontrolled hemorrhage despite these measures requires emergent surgery.

5. Immobilize the cervical spine in patients with altered level of consciousness, blunt trauma, or penetrating trauma with neurologic deficits after
careful examination for penetrating injury, bleeding, hematoma, or bruits/thrills. Cervical collars should not be placed at the expense of
monitoring injuries or the ability to perform life-saving procedures.

6. All penetrating wounds that violate the platysma muscle mandate surgical consultation. Unstable patients with penetrating neck trauma require an
emergent surgical or interventional radiologic procedure. Therefore, egress from the ED should not be delayed for unnecessary procedures or
tests. Stable patients should undergo diagnostic evaluation for deep structure injuries (Fig. 163-2).

7. Penetrating wounds that do not violate the platysma require standard wound care and closure and the patient may be discharged if they are
asymptomatic.

8. Patients with blunt neck trauma and hard signs of injury require emergent surgical consultation (Table 163-1). Patients with stable, symptomatic
blunt neck trauma should be aggressively evaluated for injuries to deep structures utilizing MDCTA and other modalities. Surgical consultation and
admission for these symptomatic patients are advised even if no injury is seen on the initial study.

9. The optimal management of asymptomatic blunt neck trauma patients remains unclear. Consider liberal use of MDCTA (and other adjunctive tests
as necessary) and extended observation (4 to 6 hours) to detect delayed respiratory and neurological dysfunction. This is especially recommended
for patients with risk factors for blunt cerebral vascular injury (Table 163-2).

10. Address the associated psychosocial issues of strangulation victims.

FURTHER READING

For further reading in Tintinalli's Emergency Medicine: A Comprehensive Study Guide , 8th ed., see Chapter 260, “Trauma to the Neck” by Bean Ashley
S.

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